Behavioural therapy and Telemedicine
The new frontier in delivering Behavioural therapy?
Liz Murray*, Seonaid Anderson, Research Manager at Tourettes Action and Tara Murphy, Great Ormond Street Hospital NHS Trust.
Behavioural therapy can be useful for many people with tic disorders and although, not a cure, can be very effective in helping people to gain control over their tics. The most supported behavioural therapy is called Habit Reversal Therapy (HRT). More recently, HRT has been shown to be effective as part of a package alongside other elements of therapy, known as Comprehensive Behavioural Intervention for Tics (CBiT). Another model which has been researched and also found to be effective in facilitating people get more control over their tics is exposure and response prevention (ERP).
How does the treatment work?
Both CBITS and ERP packages start with an educational aspect; learning about Tic Disorders and Tourette Syndrome (TS). This includes: understanding the causes (as much as they are known), appreciating that it is a brain-related condition as well as finding out about the usual course of tics and the other conditions that often co-occur in individuals with TS. This information can help cope with having a tic disorder. Understanding what a tic disorder is, is very important and remembering that having tics is only a very small part of a person.
Other aspects of the therapies involve identifying environmental events that make tics worse for an individual. A therapist will help a person with tics to understand what tends to happen before and after a ‘bout’ of tics and perhaps activities they do reduce the tics they have in these particular situations.
Both Habit Reversal Training and Exposure and Response Prevention help the person to get used to feeling the urge to tic without ticing. Neither approach will result in more tics once the person stops using the strategy or cause the person with tics to feel greater discomfort. Hopefully, as the individual with tics uses the strategies more and more the tic control occurs more automatically for them. Both treatments are described in manuals which can be followed by your therapist.
There is growing research finding ways to make behavioural therapies for tics more available to a broader range of people. Researchers have been trying out new approaches such as offering group-based treatment, delivering CBiTS and ERP using telemedicine (via the internet with programs such as Skype) and using online materials.
In this article we thought it would be helpful to focus on how telemedicine has helped offer treatment to people with tics.
Following a behavioural therapy program using telemedicine (e.g. Skype) has been shown to be effective in both research studies and in usual clinic practice. The process is the similar to individual face to face therapy. You ‘meet’ the therapist on camera, in your own home or local clinic and they offer treatment from their clinic. The procedures in the therapy should be the same and cover the same material, which can be sent electronically, which is also convenient. The program should be the same length as face to face treatment and results of effectiveness appear to be similar. Using telemedicine means that people do not have to miss work or school through travel to clinics.
We asked some people to feedback on the experience of having therapy for tic management using telemedicine. The information below was kindly written by a teenager and an adult who had behavioural therapy for tics using telemedicine:
Teenager's views: ‘I have recently had therapy (Exposure and Response Prevention) through tele-medicine for my Tourettes and OCD. I was quite afraid when first being told I was going to have therapy over skype, as I thought it just wouldn't be the same, but due to the fact I live hundreds of miles away from GOSH (Great Ormond Street Hospital), it was one of my few options. Luckily I got to meet my therapist, Fiona, in person to start the treatment and we then carried on with it via Skype. I think this was crucial and would recommend anybody doing this to meet the person first. I have built up a brilliant relationship with my therapist and the fact that we are not literally sat opposite each other has never taken away anything from my treatment, it also means that I do not have to travel up to GOSH every week for therapy and that sometimes I can do it in my pyjamas! I would recommend it for anybody’.
Adult's views: Initially, I was a little bit reluctant about whether the Skype sessions would work ... but they exceeded my expectations!
Attending the weekly appointment was very easy as I didn't have to get stressed about being somewhere at a particular time and take any public transport ... which would have increased my tics.
It felt pretty relaxing having the sessions from the comfort of my home with a cup of herbal tea.
Liz Murray (my therapist) made me feel at ease very quickly. She is a lovely lady and we connected very well. I was even able to introduce her to my partner (which was possible because we were doing our sessions via Skype).
What I found most useful was to identify every single tic I have ... and then on a weekly basis we would find a competing response for it. It was also useful to identify whether there were some premonitory urges prior to a tic in order to cut the circuit before the tic actually happened. In this way, I am reprogramming my mind to stop ticking when I am in certain situations.
This was extremely helpful when brushing my teeth, having a shave, chopping food (or cooking in general), doing the dishes ... as these tasks had become quite dangerous and very frustrating.
I have noticed that my tics have become more manageable under certain situations.
There was an exercise that I felt didn't work for me. I had to keep a count of all my tics in a period of 30 minutes. I just couldn't do it. I thought I would video myself so I could watch myself tic and start counting ... but that was quite upsetting and I felt really down about it. Liz was very understanding about it and we decided to give that exercise a skip.
Our Skype sessions didn't come without glitches. On certain occasions, the internet connection was a little weak. But overall it went really well. If you think about it ... even going for a face to face session can have a glitch: public transport might be delayed and you arrive late to your appointment.
Would I recommend Skype Cbit sessions? Definitely YES!
The Good and The Bad
There are advantages to delivering behavioural therapy using telemedicine and also challenges. It makes for a very flexible way of working which can suit many people and certainly reduces travel time and associated expense. It allows the therapist to use techniques which may not be available in the clinic and helps people to feel comfortable in their own home. It can also have drawbacks in that the internet can falter, camera’s don’t work sometimes and not being physically in the same space means that you cannot practice the strategies with the individual in local settings such as shops and public transport, which can be useful sometimes.
Currently, there are no known confidentiality reasons to not using the online video approach which is as secure as offering treatment via telephone. Another application which has the potential to be used is called “FaceTime”, which is anApple product, for use exclusively between Apple devices, which many people have now and it passes patient security encryption conditions in the United States.
Treatment via telephone also has good evidence for conditions such as OCD, although is unlikely to work well for tic treatments as it is essential that the therapist is able to see the person, therefore having a camera for the patient and therapist to see one another is essential.
Training and supervision for therapists
Skype can also be really useful for clinical supervision and consultancy, for example professionals discussing cases and guiding treatment. Skype supervision is an efficient and affordable way to ensure that professionals across the country can access a wealth of expertise, support and training. Dr Tara Murphy from Great Ormond Street Hospital and Tourettes Action offer bi-annual clinical supervision sessions for behavioural therapists. The purpose of these meetings is case discussion for clinicians using behavioural therapies to treat people with tic disorders. The sessions aim to support the clinician’s practical experience in both diagnosing and treating patients with TS.
Future supervision sessions
Tourettes Action holds consultation sessions for behavioural therapies for TS will be held at Great Ormond Street Hospital session. These sessions are open to qualified clinicians working with children / adults with TS. If you would like more information please contact Seonaid@tourettes-action.org.uk
Tourettes Action behavioural therapists list
Tourettes Action are keen to help as many people as we can find behavioural therapy for tics and Tourettes Syndrome. We have been working hard building up the behavioural therapist list and keeping it up to date. Please email help@Tourettes-Action.org.uk to get a copy.
We have been training more therapists and providing ongoing supervision to support them so that they will be able to see and treat more people who want help with tics and TS. We are aware that not all areas of the UK are covered by our list, however, many of the therapists also offer telemedicine.
Our behavioural therapist list has now been updated and you can see which therapists offer telemedicine, so it shouldn’t matter what part of the country you live in you could still have access to this kind of service.
We are committed to continue building this list and to supporting and training more therapists. If you can help us by recommending a therapist you found helpful then please contact us
We would like to thank the two people with Tourette syndrome who kindly wrote about their experiences with telemedicine for this article and to Dr Fiona McFarlane, Clinical Psychologist at Great Ormond Street Hospital and Dr Victoria Pile, Clinical Psychologist at TANDEM, Evelina Hospital, for their comments. Thanks also to Craig Thomas Smith for creating the illustration of telemedicine for this article.
* Behavioural therapist delivering online therapy for TS:
A psychologist delivering online therapy for TS: Liz Murray, delivers behavioural therapies for Tourette syndrome to adults online. Liz is a British Psychological Society (BPS) Chartered psychologist and a Health and Care Professions Council (HCPC) Registered psychologist. She trained at the very first clinical training school for tics and Tourette Syndrome in London in 2011 and has continued training in every year since. Liz has a keen interest in helping to increase access to therapy via video and Telehealth systems.
The subject of telemedicine and TS has also been picked up by some of the media recently, see a recent article in The Telegraph.